University of Groningen
Pediatric abdominal injury
Nellensteijn, David
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Nellensteijn, D. (2015). Pediatric abdominal injury: initial treatment and diagnostics [S.l.]: [S.n.]
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Chapter 1
Introduction and outline of the thesis
Introduction and outline of the thesis
Introduction
Being intensively involved in the treatment of children sustaining blunt abdominal trauma,
we once posed the simple question: ”What is the evidence for one week bed rest in children with liver injury?” This question eventually led to the research resulting in this thesis.
In this introduction we will first outline the incidence of pediatric trauma whereafter we will
focus on some of the differences between children and adults. Differences in physiology
and anatomy form the background for many of the following chapters. All physicians treating children with possible (abdominal) injury should be aware of these differences. In the
present thesis, focus is first on the diagnostic process in children with suspected abdominal
injury. After delineating the role of CT scan, several possible alternative diagnostic modalities will be discussed. Subsequently clinical outcome in relation to conceivable treatment
modalities in children with blunt trauma sustaining solid organ injuries are evaluated. The
introduction will be followed by a brief outline of the thesis.
Pediatric trauma
Epidemiology
Trauma still is worldwide the number one cause of death for children below the age of 18
(between 1 and 18 years) even in well-developed and wealthy countries such as the Netherlands.1 Roughly two third of these fatalities are caused by traffic injury in the Netherlands.
Due to the many preventive precautions that have been implemented in traffic such as
mandatory child seats and the technical improvements in motorised vehicles the incidence
death rate has dramatically declined. In 1983 the Dutch annual number of fatal paediatric
road traffic accidents was 191 (0-16 years), while in the year 2012 it has decreased to 27.
Figure 1 depicts annual mortality and causes for the years 1983 and 2012.1
Injury can be inflicted by blunt force trauma and penetrating trauma. In several parts of the
world, penetrating trauma is the most prevalent. However, in Europe, >90% of injuries are
caused by blunt trauma. Seriously injured children often suffer from multiple injuries. Head
injury is present in the majority of cases and accounts for 75% of deaths.2,3
The types of injury mechanisms are age dependent. In infants, non-accidental injury is
most prevalent whereas, for toddlers, falls are the predominant injury mechanism. In older
children, road traffic accidents and sports injuries predominate. More than 50% of road
traffic accidents involve the child as a pedestrian and a further 20% as cyclists. For the
Dutch population, bicycle and motorcycle accidents might predominate in older children.
Whether this indeed is the case will be investigated in the chapters regarding liver and
splenic injury of the present thesis.
Pediatric trauma deaths have a trimodal distribution with 50% dying at the scene from
either severe head injury or major hemorrhage. A further 30% die within the first few
13
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14
Hoofdstuk 1
Figure 1 Dutch pediatric fatalities in the years 1983 (blue) and 2012 (red) and
Chapter 1
causes
of death.
figure 1: Dutch pediatric fatalities in the years 1983 (blue) and 2012 (red) and causes of death.
400
350
300
250
200
150
100
50
0
1
Traffic
2
Fall
3
Drowning
4
Poisoning
5
Other
6
Total
Traffic
Drowning
Poisoning
hours
from head Fall
injury, hemorrhage,
or airway
emergencies.Other
Late deaths Total
due to organ
failure and sepsis are often due to inadequate initial resuscitation.
Abdominal trauma accounts for about 10% of8trauma in children but is the leading cause
Table 1; 1994 AAST revised Hepatic injury score.
of initially unrecognized fatal injury. It is second only to airway problems as the most
Grade*
Injury type
Description of injury
frequent cause of preventable death.2 Therefore a thorough analysis of injury patterns is
I
Subcapsular,
<10% surface area
important
inHematoma
the care of children with
possible intra-abdominal
injury.
Laceration
Capsular tear, <1cm
differences between childrenparenchymal
and adultsdepth
II
Hematoma
Physiological differences
Subcapsular, 10%-50% surface area
intraparenchymal, <5 cm in diameter
Stress responses
in children are different
from
those
in adults.
As stroke
volume
is relatively
Laceration
Capsular
tear,
1-3cm
parenchymal
depth
that does
not
involve
a
trabecular
vessel
constant in children, tachycardia is the only way to increase heart minute volume. Children
are
maintain hemodynamicSubcapsular,
stability for>50%
a long
period
with only
subtle
III able to Hematoma
surface
areaofortime,
expanding;
ruptured
subcapsular
or
parecymal
hematoma;
intraparenchymal
signs of deterioration (often only a mild tachycardia) before they rapidly develop severe
hematoma > 5 cm or expanding
hypovolemic shock. Bradycardia should be considered as a near fatal sign.
Laceration
>3 cm parenchymal depth or involving trabecular vessels
As the skin area of children is relatively large, hypothermia will develop relatively rapidly
IV
Laceration
Laceration
involving segmental
or hilarand
vessels
producing
when
compared
to adults. Hypothermia
in combination
with acidosis
coagulopathy
major devascularization (>25% of spleen)
is – just as in adults – the lethal triad. Hypothermia should therefore be avoided whenever
V
shattered
spleen
possible,
andLaceration
can often be achievedCompletely
with relative
ease such
as by heating of the emergency
Vascular
Hilar vascular injury with devascularizes spleen
room.
Introduction and outline of the thesis
Anatomical differences
Due to the size of the patient, injury patterns differ in children when compared to adults.
Children will more often suffer from (concomitant) brain injury due to the relatively large
size of their head. It is one of the reasons that brain injury is the cause of death in 75%
of the cases.
When compared to adults the abdominal organs are closely packed together.
Children have relatively little abdominal muscle or fat mass, which can absorb some of the
impact.
The ribcage is very elastic, offering less protection to the liver and spleen. Also, the diaphragm is placed more horizontally, thus displacing the liver and spleen downwards, which
further increases the vulnerability of the intra-abdominal organs. Children have a relatively
small pelvis placing the bladder more intra-abdominally and thus less protected. All these
factors contribute to the vulnerability of the abdomen in children.3
Finally, although the principles of acute trauma care do not differ between children and
adults, in children even “simple” interventions such as placement of an intravenous catheter can be more difficult because of the smaller size of the vessels, while medication
regimes also differ from those in adults. For all these reasons, the child with possible severe
trauma can therefore pose a significant challenge for ‘adult’ physicians.
diagnosing abdominal injury in children
Assessment
Potentially injured children are assessed through the ATLS/APLS principles: ABC (DEFG) and
treat first what kills first.4 After establishing a free airway and an adequate oxygenation/
ventilation, circulation is assessed. Vital parameters are age-dependent. Signs of shock will
only become apparent after a loss of > 15% of the total circulating volume. Hypotension
will occur only after an acute loss of 25% of the total circulating volume. When there are
signs of shock 20 ml/kg warm isotonic crystalloid is administered, which can be repeated.
This first bolus comprises 25% of the circulating volume, after the second bolus 50% of
the circulating volume has been replaced. Signs and symptoms of shock can be very subtle;
a mild tachycardia is often the only sign and can be easily mistaken as a sign of pain or
discomfort. Systolic pressure can even be increased due to the shock response. In this way,
children are different from adults. This is important when considering the presence of
hemodynamic (in)stability.
The definition of hemodynamic stability in children is subjective to multiple variable parameters. The assessment of hemodynamic instability is an evolving process, in which the
physiological reaction to fluid challenges might be more important than the first read-out
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Chapter 1
of the monitor. Children who respond to fluid boluses can be considered as ‘responders’,
and management is different from those who do not respond. Children who are stabilized
after a bolus of 2x25% of the circulating volume are considered hemodynamically stable
according to the APLS definition.
In case of severe hypothermia, coagulopathy and acidosis ‘damage control surgery’ might
become necessary: in the case of abdominal injury this consists of stopping the bleeding
as soon as possible, preventing further fecal spill (e.g. by stapling the bowel), (temporarily)
closing of the abdomen followed by further stabilization in the pediatric intensive care.
While very important in children, a more detailed discussion of the damage control principle goes well beyond the present chapter.
After stabilisation of vital functions and completion of the primary survey, a complete
physical examination is carried out. An initial normal physical examination does not rule
out internal injury. Especially in children this is an important point. Small external injuries,
e.g. a small bruise due to a handlebar injury, can be a sign of severe intra-abdominal injury.
Obvious lesions such as the seatbelt sign are pathognomonic for severe intra-abdominal
injury. Preferably, the physical examination is repeated by the same (senior) physician at
regular intervals after the accident, as changes in the examination can offer important
insights in the presence or absence of injury. Repeated physical examination is therefore
essential in the assessment of the abdominally injured child and its importance cannot be
overstated.5
In the secondary survey X-rays of the chest, pelvis and cervical spine are obtained, Focussed
Assessment with Sonography for Trauma (FAST – aimed at identifying free intra-abdominal
fluid) or regular ultrasound imaging of the abdomen is performed and blood samples are
obtained.
In the absence of hemodynamic instability, a multi-phase contrast enhanced CT is generally
performed when abdominal injury is suspected (e.g. when intra-abdominal fluid is present
on FAST). Also in the Netherlands and thus in the University Medical Centre Groningen,
(UMCG) a CT scan is considered the investigation of choice for determining the presence
and extent of intra-abdominal injury in hemodynamically stable children.3 However, indications for CT scan are rather ambiguous in most centres. They often consist of a high index
of suspicion (e.g. a seatbelt sign with abdominal tenderness), laboratory disturbances
indicative of intra-abdominal injury (e.g. raised liver function tests or raised amylase) or
ultrasound findings such as the presence of free fluid or the suggestion of injury to the
parenchymatous organs. Hemodynamic instability, as defined by the APLS, should (in nonresponders) be seen as an indication for emergency surgical intervention and is thereby a
contra-indication for CT scan of the abdomen.4
Introduction and outline of the thesis
Blood analyses
Laboratory testing contributes significantly to the identification of children with intraabdominal injuries after blunt trauma.6 Since physical examination and hemodynamic
parameters are frequently unreliable for the abdominally injured patients, serum analyses
are helpful tools in the diagnostic workup, e.g. to assess (persistent) blood loss or to get
an indication of the presence of organ specific injury. While detailed discussion of the
subtleties of serum analysis goes beyond the scope of this chapter, a specific serum marker
for abdominal injury would be a valuable addition to the diagnostic workup. It could save
valuable time, and reduce costs and unwarranted medical examinations.
Imaging techniques
Ultrasonography and FAST are quick and non-invasive investigations, readily available in
most hospitals. While FAST aims at a rapid identification of free fluid (in Morrison’s pouch,
the perisplenic area, the pelvis and the pericardium), a formal ultrasound can be performed
in stable patients. With added Doppler, ultrasonography can even assess flow in essential
vascular structures. It has no ionising radiation and sedation is not needed for adequate
investigation. In hemodynamically unstable patients with blunt abdominal trauma, bedside
ultrasound in the emergency room should be the initial diagnostic modality performed
to identify the need for emergent laparotomy.7 It is also very suitable for follow up of
abdominal injury.
However, ultrasound also has its downsides. It is operator dependant and although it is
reasonably sensitive to free fluid, it is not very reliable for the assessment of solid organ
injury, let alone grading of injuries.
CT imaging is considered the golden standard for imaging of abdominal injury due to its
accuracy. It is relatively quick and generally available in most hospitals and with the use of
intravenous contrast it can even distinguish and localize active bleeding.
The AAST issued the Organ Injury Scales (OIS) to be able to compare patient groups for
research purposes.8 Concurrently the development of the CT scan made swift and relatively
accurate initial analysis of the abdominal injury possible. The CT scan has thus become the
gold standard of diagnosing intra-abdominal injury in children and has adapted the use of
the OIS for grading injuries. Table 1 depicts the AAST grading system for hepatic injury. For
all organ injuries a comparable grading system is available.
CT imaging also has its downsides. It has a risk of contrast reactions, can be relatively time
consuming and is a serious ionising radiation hazard for patients. Also, there is an inherent
danger in transporting patients to and from the CT suite, which itself poses danger as
monitoring and intervention options in the CT suite are suboptimal at best.
17
1
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Chapter 1
Table 1: 1994 AAST revised Hepatic injury score.8
Grade*
Injury type
Description of injury
I
Hematoma
Subcapsular, <10% surface area
Laceration
Capsular tear, <1cm
parenchymal depth
II
Hematoma
Subcapsular, 10%-50% surface area
intraparenchymal, <5 cm in diameter
Laceration
Capsular tear, 1-3cm parenchymal depth that does not
involve a trabecular vessel
III
Hematoma
Subcapsular, >50% surface area or expanding; ruptured
subcapsular or parecymal hematoma; intraparenchymal
hematoma ≥ 5 cm or expanding
Laceration
>3 cm parenchymal depth or involving trabecular vessels
IV
Laceration
Laceration involving segmental or hilar vessels producing
V
Laceration
Completely shattered spleen
Vascular
Hilar vascular injury with devascularizes spleen
major devascularization (>25% of spleen)
While CT and ultrasound remain the imaging tests of choice during the golden hour,
the subsequent management of patients after trauma, either post surgical or during a
watchful waiting algorithm sometimes requires repeated advanced cross sectional imaging. Given the lack of radiation dose and the multiple tools in the MRI armamentarium (i.e.
MR cholangiopancreatography), the use of MRI for post-acute imaging does have a role
in the assessment and certainly the follow-up of abdominal injury, particularly in young
patients. When the child has been stabilized, MRI can be an important adjunct, e.g. in
diagnosing pancreatic injuries.
Using MRI scanners in an emergent fashion is impractical for several reasons. Many
emergency departments have CT scanners nearby; many do not have easy access to MRI
scanners or MRI technologists waiting on standby for trauma studies. It is often impossible
or impractical to perform the necessary safety screening of trauma patients. It is necessary
to have the surgical trauma team close at hand, often inside or just outside the scan room,
making screening of great importance and the risk of projectiles a major hazard. While
rapid MRI protocols of the abdomen could easily be performed with scan times similar
to that of the CT, trauma patients often undergo total body scanning for concomitant
injuries. For reasons of accessibility, safety, and the need to scan multiple body parts in
rapid succession, CT is still considered the golden standard of trauma imaging during initial
analysis despite the radiation exposure.9
Introduction and outline of the thesis
Management of paediatric abdominal trauma through the years:
from non-operative management to aggressive surgery and back
During the last 100 years the management and approach to parenchymatous visceral injuries has fluctuated from surgical caution at the turn of the previous century as advocated
by Beckman’s “intelligent conservatism” in the 1920s, followed by aggressive surgical
intervention throughout most of the century, and finally a move back towards an initial
non-operative approach.
Nowadays the selective, non-operative management (NOM) of blunt abdominal trauma in
hemodynamically stable patients is well established and accepted as initial modus of treatment.10-15 However, as recently as 30 years ago this was not the case. The management of
choice at that time was an aggressive approach of mandatory operative repair based on
the concept that a significant injury will not heal spontaneously, and therefore, the earlier
the surgical intervention the better. In retrospect, the often unnecessary and sometimes
technically difficult surgery led to increased morbidity and mortality.16
In the sixties, the recognition of Overwhelming Post Splenectomy Infections (OPSI) resulted
in the wish for spleen preserving therapies, specifically for children. After splenectomy
the lifetime risk for OPSI is around 5%, with a mortality rate of about 50%, which makes
it a substantial risk specifically for children.17 This prompted pediatric surgeons to be as
conservative as possible with injury to the spleen, and set the tone for the development
of NOM.
The development of endovascular treatment options over the last decades, such as the
Selective Arterial Embolization (SAE), have added a potential treatment modality that
favours the outcome of non operative management in abdominal injury.18
Since the seventies, a shift from operative to non-operative treatment for injury to the
intra-abdominal solid organs has occurred.18 Pediatric surgeons were among the first to
adopt this form of treatment. Even for the higher grades of injury in the various organs,
high success rates with this policy of “watchful waiting” are achieved.20 In this regard it
is interesting to note that there is a poor correlation of grades of injury and the need for
surgical intervention.21,22 The success rate of NOM, when necessary assisted by SAE, can
reach up to 95%, even for the higher grades of injury23.
Gradually the success rate of NOM rose to the extent that guidelines for non-operative
treatment of splenic and hepatic injuries were issued by the American Paediatric Surgical
Association (APSA) in the year 2000.24 (Table 2)
These guidelines provide support to maximize patient safety and assure efficient, costeffective utilization of resources and are based on injury grades using CT imaging. They
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Chapter 1
Table 2: Treatment of liver injuries according to the APSA guidelines24
Grade I injury
Grade II injury
Grade III injury
Grade IV injury
ICU stay
none
none
none
1day
Hospital stay (days)
2
3
4
5
Pre discharge imaging
none
none
none
none
Post discharge imaging
none
none
none
none
Activity restriction (weeks)
3
4
5
6
provide an algorithm for treatment, observation on ICU and in hospital, repeat of imaging
and the period to minimise physical exercise.
Challenges in diagnosing and treating blunt abdominal injury in children
Treatment of abdominal injuries in hemodynamically stable children is supposedly based
on grade of injury as diagnosed on CT imaging. Whether this corresponds with the actual
clinical course is unknown. The difficulty of NOM is that no one knows exactly what is
going on inside the abdomen; CT images are only an approximation of the reality. While
we tend to treat children based on interpretation of these images, it is unknown whether
there is a good agreement between radiologists and surgeons regarding the severity of
injury as observed on CT. Also, while we tend to treat children based on interpretation
of these CT images, it is well known that the most sensitive prognostic tool for success
of NOM is repeated (abdominal) examination of the child by the same investigator.25 Another important observation is that intra-operative findings and CT-findings do not always
match.26 Frequently a splenic or hepatic rupture is found on explorative laparotomy for
concomitant injuries. Likewise the pancreatic duct can be transsected where CT imaging
had not even raised suspicion of injury. Sensitivity for perforation of a hollow viscus, which
is besides hemodynamical instability the only absolute indication for laparotomy, is low. For
duodenal injury e.g., sensitivity does not exceed 50%. The administration of oral contrast
does not improve this.27
Maybe even more important, CT has several major disadvantages. Besides the fact that
CT scanning implies – in most hospitals – a time-consuming and potentially dangerous
transport of the child from the safe and controlled environment of the shock room to a
“doughnut of death” in which monitoring and acute interventions are much more cumbersome, CT itself carries the risks of radiation induced injury.28,29
Ionising radiation such as in X-ray diagnostics brings on a lifetime risk of developing
malignancies induced by the investigation. Specifically in children the radiation is known
to possibly bring extra harm. For a given radiation dose, there is a difference in cancer
risk from radiation exposure for children compared to adults for several reasons: tissues
Introduction and outline of the thesis
and organs that are growing and developing are more sensitive to radiation effects, an
infant has a longer life expectancy in which to manifest the potential oncogenic effects of
radiation, and finally the radiation exposure from a fixed set of CT parameters results in a
dose that is higher for a child compared to an adult.
It is therefore of the utmost importance to adapt our evaluation algorithm to a safe evaluation as regards to detection of injuries that may need treatment but with minimal radiation
exposure. Even while following the ‘As low as reasonably achievable’ (ALARA) principle,
it is estimated that 1:1000 children might die as a result of a radiation induced tumor.28,29
Best is therefore to avoid radiation exposure completely. For abdominal injury in children,
little is known about the diagnostic yield of CT scan in the light of radiation exposure.
To conclude, while non-operative management of children with intra-abdominal injury has
proven to be a very effective treatment modality, many questions and challenges remain in
the diagnostic workup and treatment of these children. Some of these will be addressed
in this thesis.
In the first part of the thesis we will describe the current diagnostic work-up in children
with suspected intra-abdominal injury in our center. We will investigate whether CT
scan is a reliable tool for diagnosing intra-abdominal injury. Also we will describe the
diagnostic yield of CT scan in relation to the risks associated with radiation exposure. In
a separate chapter we will perform a similar analysis for repeat CT scans after referral to
our center. Subsequently we will study the accuracy of a novel abdominal injury score for
children and a novel trauma marker. Both are adjuncts to routine care, which might aid in
the decision to obtain a CT scan. In the second part of the thesis we will investigate daily
practice in our hospital for children with intra-abdominal injury, and compare our results
with the literature. In subsequent chapters injury to the liver, spleen and pancreas will be
discussed. In these analyses we will focus on the results of non-operative management
and we will try to identify areas for further improvement in clinical management for these
patients.
21
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Chapter 1
Outline of the thesis
A general introduction to pediatric trauma and a short outline of the thesis is provided in
chapter 1.
Subsequently we will focus on the diagnostic process in children with suspected intraabdominal injury. The American Pediatric Surgery Association has issued guidelines for the
treatment of hemodynamically stable children with isolated injury to the liver or the spleen.
These guidelines are based on the grading of injury on CT.
In chapter 2 the reliability of a CT based grading system of liver injury in paediatric abdominal trauma is investigated. To this end we determine the inter- and intra observer
agreement for liver injury as graded following the Organ Injury Scale from the American
Association for the Surgery of Trauma. Several specialists, including radiologists, paediatric
surgeons, trauma surgeons and hepatobiliary surgeons all independently and repeatedly
grade hepatic injury on a CT scan and inter- and intra-observer variation is computed.
In chapter 3 we investigate the additional radiation risk of abdominal CT and calculate
the estimated lifetime risk for malignancy and additional mortality risk in the light of novel
diagnostic findings that might or might not alter management. This way we will determine
the diagnostic yield of CT scan in children with suspected intra-abdominal injury.
Since progressively more injured children are being referred to specialist centres and subsequently undergo a CT scan in both facilities, we set out to compute the extra radiation
dose and associated risks of a repeated abdominal CT after transferral to our center. This
is described in chapter 4, again in the light of novel diagnostic findings possibly altering
management.
Combining readily available data into an abdominal injury score might also aid in preventing unnecessary diagnostic procedures such as CT scan. To this end we will retrospectively
validate the Blunt Abdominal Trauma in Children score (BATiC) in a large cohort of patients
in chapter 5.
In chapter 6 we investigate the kinetics of plasma Liver Fatty Acid Binding Protein (L-FABP) as
a possible marker for intra-abdominal (hepatic) injury. In a pilot study (comprised of the first
50 patients of a large prospective trial into the development of biomarkers for abdominal
injury and the development of the Systemic Inflammatory Response Syndrome and Multiple
Organ Failure) we measured L-FABP in plasma obtained at three hour intervals from adult
patients who were administered to the Shock Room with (suspicion of) severe trauma.
Introduction and outline of the thesis
In the second part of this thesis we will investigate injury to the intra-abdominal parenchymatous organs. As described in chapter 7 we analyse liver injury. Main endpoints are the
success rates of non-operative management (NOM) and late complications. Among others,
trauma mechanism, age; divided in different age groups, treatment modalities and length
of hospital and ICU stay are assessed.
Similar data are analysed for the children with splenic injury in our hospital, as described in
chapter 8. This chapter describes the data for all pediatric patients with splenic injury, but
also divides them into a multitrauma and isolated splenic trauma group.
Paediatric pancreatic injury is an entity on its own and described in chapter 9. It is relatively
uncommon, easily missed, and hard to diagnose even in the higher injury grades such as
transsection of the pancreatic duct that sometimes call for early surgical treatment. Several
issues on diagnostics regarding abdominal injury are raised.
Chapter 10 has been written as a discussion paper for Dutch physicians dealing with
possible intra-abdominal injury in children. Chapter 11 more profoundly discusses the
findings of these thesis and the conclusions we can draw. It also casts an eye on future
perspectives. Chapter 12 provides a summary and discussion of the main conclusions in
English and Chapter 13 in Dutch.
23
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Chapter 1
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BMJ 2013; 346: f2360
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1
Part 2
The diagnostic workup
in children with
suspected abdominal
injury